ISSN 1941-5923

© Am J Case Rep, 2014; 15: 243-245

DOI: 10.12659/AJCR.890570

Received:
Accepted:
2014.02.21
2014.03.07 Lung cancer mimicking lung abscess formation
Published: 2014.06.07
on CT images
Authors’ Contribution: A 1 Naohiro Taira 1 Department of General Surgery, National Hospital Organization, Okinawa
Study Design A C 1 Tsutomu Kawabata National Hospital, Ginowan, Okinawa, Japan
Data Collection B 2 Department of General Surgery, Okinawa Hokubu Hospital, Nago, Japan
Statistical Analysis C C 2 Atsushi Gabe
Data Interpretation D B 1 Takaharu Ichi
Manuscript Preparation E D 1 Kazuaki Kushi
Literature Search F
Funds Collection G F 1 Tomofumi Yohena
C 1 Hidenori Kawasaki
D 2 Toshimitsu Yamashiro
D 1 Kiyoshi Ishikawa

Corresponding Author: Naohiro Taira, e-mail: naohiro_taira@yahoo.co.jp

Conflict of interest: None declared

Patient: Male, 64
Final Diagnosis: Lung pleomorphic carcinoma
Symptoms: Cough • fever
Medication: —
Clinical Procedure: —
Specialty: Oncology

Objective: Unusual clinical course

Background: The diagnosis of lung cancer is often made based on computed tomography (CT) image findings if it cannot be
confirmed on pathological examinations, such as bronchoscopy. However, the CT image findings of cancerous
lesions are similar to those of abscesses.We herein report a case of lung cancer that resembled a lung abscess
on CT.
Case Report: We herein describe the case of 64-year-old male who was diagnosed with lung cancer using surgery. In this case,
it was quite difficult to distinguish between the lung cancer and a lung abscess on CT images, and a lung ab-
scess was initially suspected due to symptoms, such as fever and coughing, contrast-enhanced CT image find-
ings showing a ring-enhancing mass in the right upper lobe and the patient’s laboratory test results.However,
a pathological diagnosis of lung cancer was confirmed according to the results of a rapid frozen section biop-
sy of the lesion.
Conclusions: This case suggests that physicians should not suspect both a lung abscesses and malignancy in cases involv-
ing masses presenting as ring-enhancing lesions on contrast-enhanced CT.

MeSH Keywords: Lung Neoplasms – etiology • Lung Neoplasms – radiography • Lung Neoplasms – surgery

Full-text PDF: http://www.amjcaserep.com/download/index/idArt/890570

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This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License 243
 Taira N. et al.:
Lung cancer mimicking lung abscess formation on CT images
© Am J Case Rep, 2014; 15: 243-245

Background A

The diagnosis of lung cancer is often made based on com-

puted tomography (CT) image findings if it cannot be con-
firmed on pathological examinations, such as bronchoscopy.
However, the CT image findings of cancerous lesions are sim-
ilar to those of abscesses.

We herein report a case of lung cancer that resembled a lung

abscess on CT.

Case Report

A 64-year-old male, a current smoker with a wet cough and fe-

ver lasting for one week followed by the spontaneous resolution
of symptoms, presented to the outpatient clinic for an evalua- B
tion of an abnormal shadow on a chest X-ray. The chest X-ray
showed an area of consolidation in the apex of the right lung
(Figure 1A). In addition, laboratory tests revealed an elevated
CRP level(3.86 mg/L) and white blood cell count (8,980 ml), al-
though the levels of serum tumor markers such as CEA, CYFLA,
and ProGRP were within the normal range. Contrast-enhanced
CT showed a low-density lesion with thick ring-enhanced irreg-
ular walls in the right upper lobe. The mass measured 53×43
mm, and had poorly defined margins. The interface between
the lesion and surrounding organs was not clear. No gas col-
lection or calcification was indicated. Enlarged lymph nodes
were not detected in the mediastinum(Figure 1B). A PET/CT
scan demonstrated a high uptake in the lesion, with a maxi-
mum SUV of 8.7, and the mediastinal lymph node, with a max- C
imum SUV of 3.7, suspicious for both lung cancer and lung ab-
scess formation (Figure 1C). An abscess was initially suspected
based on the patient’s symptoms, CT image findings and lab-
oratory test results. Both a transbronchial lung biopsy (TBLB)
and CT-guided fine-needle biopsy of the lesion showed inflam-
matory cells compatible with active inflammation, No malig-
nant cells were seen, and all bacterial cultures were negative.

The patient was referred to our institution for management of

the mass one month later. We suspected that the lesion indi-
cated malignancy, as a follow-up CT scan showed an increase
in the lesion in size to 59×49 mm (Figure 2) despite the ab-
sence of symptoms, such as fever. Therefore, we planned to
perform surgery because there were no other signs of distant
metastasis based on a CT scan of the chest, abdomen and pel-
vis, brain MRI and PET/CT.
Based on the intraoperative findings, the right middle lobe
was found to be involved with the mass in the upper lobe. A
pathological diagnosis of lung cancer was confirmed accord-
ing to the results of a rapid frozen section biopsy of the le-
sion. Consequently, we performed the right upper and middle
Figure 1. (A) An X-ray shows an abnormal shadow in the right
upper lobe. (B) Chest CT with contrast enhancement
shows a ring-enhancing solid mass measuring 53×43
mm in size in the right upper lobe with significant
mediastinal lymphadenopathy. (C) A PET/CT scan
reveals a high uptake in the mass, with a maximum
SUV of 8.7, and the mediastional lymph node, with a
maximum SUV of 3.7.
lobectomy. There were no intraoperative complications, and
the patient had an uneventful recovery. The final results of

244 This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License
Taira N. et al.:
Lung cancer mimicking lung abscess formation on CT images
© Am J Case Rep, 2014; 15: 243-245
Figure 2. A follow-up CT scan shows an increase in the size of
the mass 59×49 mm.
the pathologic examination showed a pleomorphic carcino-
ma of pT2N0M0, stage A.
Discussion
A lung abscess is defined as necrosis of the pulmonary tissue
with the formation of cavities containing necrotic debris or
fluid caused due to microbial infection. CT with contrast en-
hancement is the most sensitive and specific imaging modali-
ty for diagnosing lung abscesses. On CT images, abscesses of-
ten appear as round radiolucent lesions with a thick wall and
ill-defined irregular margin.
Pleomorphic carcinoma of the lung, the final diagnosis in this
case, is rare, accounting for 0.3% to 1% of all lung malignan-
cies [1]. The prognosis of affected patients is generally poorer
than that of patients with other types of non-small cell lung
cancer [2]. Pleomorphic carcinoma was first classified as a car-
cinoma with pleomorphic, sarcomatoid, or sarcomatous ele-
ments by the World Health Organization in 1999, and in the
2003 Classification of Lung Cancers was defined as a poorly
differentiated non-small cell carcinoma, which includes squa-
mous cell carcinoma, adenocarcinoma and large cell carcinoma
Reference:
1. Rossi G, Cavazaa A, Sturm N et al: Pulmonary carcinomas with pleomor-
phic, sarcomatoid, or sarcomatous element: a clinicopathologic and immu-
nohistochemical study of 75 cases. Am J Surg Pathol, 2003; 27: 311–24
2. Mochizuki T, Ishii G, Nagai K et al: Pleomorphic carcinoma of the lung:
clinicopathologic characteristics of 70 cases. Am J Surg Pathol, 2008; 32:
1727–35
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License
that contains spindle cells or giant cells, and cancers that con-
tain at least 10% spindle cells or giant cell areas [3]. Therefore,
the preoperative diagnosis of these tumors is very difficult, be-
cause pleomorphic carcinoma is a biphasic tumor [4].
According to Kim et al. [5], pleomorphic carcinoma frequent-
ly exhibits a central area of low attenuation with substantial
enhancement in the tumor periphery on contrast material-en-
hanced CT scans, and low-attenuation areas on contrast-en-
hanced CT scans were found to correspond to areas of myxoid
degeneration, necrosis or hemorrhage in pathological speci-
mens. Therefore, in the present case, the CT image findings
were similar to those of a lung abscess.
In general, the CT image findings of lung cancer can be similar
to those of lung abscesses, as bronchial obstruction and vas-
cular involvement with resulting ischemia can lead to tumor
necrosis in cases of malignancy. In addition, FDG-PET shows
accumulation resulting from both inflammatory changes and
malignancy.
Therefore, it can be difficult to distinguish between lung can-
cer lesions and lung abscesses on CT in case in which the pa-
tient has no symptoms, including fever, and the diagnosis can-
not be confirmed on pathological examinations, such as TBLB
or CT-guided fine-needle biopsy.
In the present case, we suspected malignancy because follow-
up CT revealed an increase in tumor in size despite the pa-
tient’s lack of symptoms suggestive of a lung abscess.
Conclusions
In conclusion, this case suggests that physicians should sus-
pect both lung abscesses and malignancy in cases involving
masses as presenting as ring-enhancing lesions on contrast-
enhanced CT.
Conflict of interest statement
Naohiro Taira and the other co-authors have no conflicts of
interest to declare.
3. The Japan Lung Cancer Society. General rule for clini- cal and pathological
record of lung cancer, 6th ed. Tokyo: Kanehara Shuppan, 2003; 128–29 [in
Japanese]
4. Kakegawa S, Kawashima O, Sugano M et al: Pleomorphic lung cancer; a
clinicopathologic study. Kyobu Geka, 2006; 59(2): 110–13 [in Japanese]
5. Kim TH, Kim SJ, Ryu YH et al: Pleomorphic carcinoma of lung: comparison
of CT features and pathologic findings. Radiology, 2004; 232(2): 554–59
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